British Journal of Neurosurgery, December 2014; 28(6): 796–798 © 2014 The Neurosurgical Foundation ISSN: 0268-8697 print / ISSN 1360-046X online DOI: 10.3109/02688697.2014.940843
SHORT REPORT
Trans-foramen ovale biopsy of a parasellar lesion guided by intraoperative CT neuronavigation with MRI fusion: A case report Martin Hsiu-Chu Lin1, Ming-Hsueh Lee1, Kuo-Tai Chen1, Tao-Chen Lee1, Wan-Chun Cheng1, Ting-Chun Wang1 & Jen-Tsung Yang1,2 1Department of Neurosurgery, Chung Gung Memorial Hospital, Chiayi, Taiwan, and 2College of Medicine,
Chung Gung University, Tao-Yuan, Taiwan scanner (Siemens, Germany). The acquired images were fused with the T2-weighted MRI for planning with the Cranial Essential/Unlimited® 3.0 software (BrainLAB). The ipsilateral foramen ovale and the lateral pterygoid plate were marked on all axial CT slices, and the parasellar lesion was marked on the coronal T2-weighted MRI slices. The plan was then exported to the VectorVision® Sky navigation system (BrainLAB) and fused with the registered images for navigation. A 3D representation of the relative positions of the lesion to the osseous structures was obtained and the proposed trajectory through the foramen ovale into the lesion using Hartel’s puncture technique was simulated. The biopsy was done with the coaxial technique; the foramen ovale was traversed and the lesion was punctured with an outer coaxial introducer needle (17 ga 10.5 cm; Angiotech) and through it, an inner SuperCore™ biopsy instrument (18 ga 21.5 cm; Angiotech,). Under neuronavigation, multiple cores were taken at different depths and also from different trajectories to ensure a high diagnostic yield. The diagnosis of disseminated germinoma was made and the patient responded well to craniospinal irradiation with boosts to the tumours (Fig. 2C and D).
Abstract A 23-year-old male presented with a parasellar lesion which was suspected as disseminated intracranial germ cell tumour. The diagnosis of germinoma was made using immunohistochemistry from percutaneous trans-foramen ovale biopsy. This report describes the role of neuronavigation-guided biopsy through the foramen ovale for lesions in the parasellar region. Keywords: biopsy; foramen ovale; germ cell tumour; neuronavigation
Case report A 23-year-old male presented with subacute onset of right trigeminal and facial nerve deficits. On brain computed tomography (CT) scan, he was found to have homogeneously hyperdense lesions in the suprasellar and pineal region, and a central calcification in the pineal lesion. A third lesion, which appeared heterogeneous, was seen in the cerebellopontine angle abutting the brainstem and extending over the petrous apex into the parasellar region (Fig. 1A and B). The lesions were better defined on contrastenhanced magnetic resonance imaging (MRI; Fig. 1C and D), the rest of the craniospinal axis appeared normal. The cerebrospinal fluid tumour markers showed mild elevation of beta-human chorionic gonadotropin (8.0 IU/L), and alpha-fetoprotein was not grossly elevated ( 10 μg/L), the fluid cytology was unremarkable. A provisional diagnosis of germinoma was made. Under local anaesthesia, a core needle biopsy via the percutaneous route through the foramen ovale guided by intraoperative CT-based neuronavigation with MRI fusion was executed (Fig. 2A and B). Briefly, the patient was placed in supine position, the ENT reference array (Kolibri™ ENT System, BrainLAB, Heimstetten, Germany) was secured to the patient’s forehead. A head CT scan was performed at 1.5-mm intervals, 120 kV, 120 mAs, with the Somatom Sensation Open sliding gantry CT
Discussion Biopsy of lesions in the parasellar region, provided it can be done with minimal morbidity, is preferred in certain instances over open surgery as it allows tissue-based pathological diagnosis, neoplastic or otherwise, in a step towards definitive therapy and prognostication, and it may avoid the risks of open surgery entirely. Biopsy of intracranial lesions is traditionally performed under stereotaxy via the transcranial route that is associated with a high diagnostic yield and a low morbidity. However, the accessibility of the parasellar region through the foramen ovale based on favourable preoperative simulation offers an alternative route for biopsy without the need of a burr hole and the added risks of brain transgression. The intraoperative registration technique
Correspondence: Jen-Tsung Yang, Department of Neurosurgery, Chung Gung Memorial Hospital, 6 Sec West, Chia Pu Rd, Pu Tz City, Chiayi, Taiwan. Tel: 886-5-3621000 extension 2864. Fax: 886-5-3623002. E-mail: [email protected] Received for publication 19 February 2014; accepted 7 June 2014
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Fig. 1. (A) and (B) Plain brain CT showing the cerebellopotine angle, suprasellar and pineal region tumours. (C) and (D). Contrast-enhanced MRI showing the same tumours.
using the ENT reference array provides a simple alternative to fiducial markers and neuronavigation-guided, percutaneous puncture also eliminates the bulk of the hardware in frame-based and frameless stereotactic systems. The technique of neuronavigation for the cannulation of foramen ovale has been demonstrated in several case series including our own for the treatment of trigeminal neuralgia.1 The necessity of neuronavigation for ablative procedures is debatable, but the superior visual-spatial information the system provides can be advantageous especially in those with a difficult-to-access foramen ovale. For ablative procedures, the target Gasserian ganglion occupies a relatively constant location to the foramen ovale, a greater emphasis is placed on the reproduction of pain in the affected trigeminal nerve distribution upon electrophysiologic stimulation, by contrast, in biopsy procedures, the location of the target lesion can be varied and more intimately associated with the critical neurovascular structures in the parasellar region, the biopsy needle may need to be advanced further beyond the opening of the foramen ovale, more towards the mid-line and supero-posterior structures, which may place the cavernous segment of the internal carotid artery and the
brainstem at risk, therefore, accurate trajectory planning, precise lesion targeting and visualization is essential. Messerer et al. presented the largest case series on the percutaneous biopsy of lesions in the cavernous sinus, their technique employed detailed pre-operative multi-modality image work-up and the aspiration of target lesion by the biopsy needle introduced coaxially under fluoroscopy, they reported a high diagnostic yield (sensitivity of 83% and specificity of 100%) and excellent concordance with the diagnosis made from open surgery (ĸ-coefficient of 0.81); however, the paucity of samples and the possibility of harvesting near the skull base and meninges might have accounted for the unproductive or discordant results.2 Sindou et al. also pointed out the approach-related difficulties in puncturing the foramen ovale under fluoroscopy, the potential for bleeding from a highly vascularized tumour, the inability to obtain samples from a firm or calcified tumour and contamination of the specimen.3 Furthermore, biopsy procedures performed under fluoroscopy is blind, indirect and relies on bony landmarks that can be inconspicuous and pre-operative simulations and trajectory planning may not always correspond to the
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Fig. 2. (A) A 3D representation of the regional structures: foramen ovale (green), lateral pterygoid plate (yellow), brainstem (blue), carotid arteries (red) and tumour (purple), the trajectory is simulated (arrow). (B) Neuronavigation-guided puncture of the foramen ovale into the parasellar lesion. (C) Left, haematoxylin and eosin stain of the specimen revealed nests of abnormal large cells with scanty cytoplasm and vesicular nuclei. Right, positive reactivity for CD117 demonstrated via immunohistochemical staining. (D) Post-craniospinal irradiation after the first 11 fractions showing near complete regression of the tumours on contrast-enhanced T1-weighted MRI.
actual procedure done under fluoroscopy. The utilization of neuronavigation with the lesion highlighted on CT or MRI can potentially overcome many of the above mentioned limitations, even though it is not a strictly ‘real time’ image, the puncture of the foramen ovale can be executed swiftly, the exact location of the biopsy needle can be determined with greater certainty, the coaxial introducer needle can be inserted into the lesion to avoid contamination, serial CT may be performed to confirm needle placement if required, and multiple trajectories and needle passes can optimize the specimens obtained. The current literature lacks data on the accuracy of neuronavigation for the trans-foramen ovale biopsy of parasellar lesions, a cadaveric or phantom study of the system in the future would be of value in better defining the benefits of this approach.
Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper.
References 1. Lin MH, Lee MH, Wang TC, et al. Foramen ovale cannulation guided by intra-operative computed tomography with intergrated neuronavigation for the treatment of trigeminal neuralgia. Acta Neurochir (Wien) 2011;153:1593–9. 2. Messerer M, Dubourg J, Saint-Pierre G, Jouanneau E, Sindou M. Percutaneous biopsy of lesions in the cavernous sinus region through the foramen ovale: diagnostic accuracy and limits in 50 patients. J Neurosurg 2012;116:390–8. 3. Sindou M, Chavez JM, Saint Pierre G, Jouvet A . Percutaneous biopsy of cavernous sinus tumors through the foramen ovale. Neurosurgery 1997;40:106–10.
Copyright of British Journal of Neurosurgery is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
SHORT REPORT
Trans-foramen ovale biopsy of a parasellar lesion guided by intraoperative CT neuronavigation with MRI fusion: A case report Martin Hsiu-Chu Lin1, Ming-Hsueh Lee1, Kuo-Tai Chen1, Tao-Chen Lee1, Wan-Chun Cheng1, Ting-Chun Wang1 & Jen-Tsung Yang1,2 1Department of Neurosurgery, Chung Gung Memorial Hospital, Chiayi, Taiwan, and 2College of Medicine,
Chung Gung University, Tao-Yuan, Taiwan scanner (Siemens, Germany). The acquired images were fused with the T2-weighted MRI for planning with the Cranial Essential/Unlimited® 3.0 software (BrainLAB). The ipsilateral foramen ovale and the lateral pterygoid plate were marked on all axial CT slices, and the parasellar lesion was marked on the coronal T2-weighted MRI slices. The plan was then exported to the VectorVision® Sky navigation system (BrainLAB) and fused with the registered images for navigation. A 3D representation of the relative positions of the lesion to the osseous structures was obtained and the proposed trajectory through the foramen ovale into the lesion using Hartel’s puncture technique was simulated. The biopsy was done with the coaxial technique; the foramen ovale was traversed and the lesion was punctured with an outer coaxial introducer needle (17 ga 10.5 cm; Angiotech) and through it, an inner SuperCore™ biopsy instrument (18 ga 21.5 cm; Angiotech,). Under neuronavigation, multiple cores were taken at different depths and also from different trajectories to ensure a high diagnostic yield. The diagnosis of disseminated germinoma was made and the patient responded well to craniospinal irradiation with boosts to the tumours (Fig. 2C and D).
Abstract A 23-year-old male presented with a parasellar lesion which was suspected as disseminated intracranial germ cell tumour. The diagnosis of germinoma was made using immunohistochemistry from percutaneous trans-foramen ovale biopsy. This report describes the role of neuronavigation-guided biopsy through the foramen ovale for lesions in the parasellar region. Keywords: biopsy; foramen ovale; germ cell tumour; neuronavigation
Case report A 23-year-old male presented with subacute onset of right trigeminal and facial nerve deficits. On brain computed tomography (CT) scan, he was found to have homogeneously hyperdense lesions in the suprasellar and pineal region, and a central calcification in the pineal lesion. A third lesion, which appeared heterogeneous, was seen in the cerebellopontine angle abutting the brainstem and extending over the petrous apex into the parasellar region (Fig. 1A and B). The lesions were better defined on contrastenhanced magnetic resonance imaging (MRI; Fig. 1C and D), the rest of the craniospinal axis appeared normal. The cerebrospinal fluid tumour markers showed mild elevation of beta-human chorionic gonadotropin (8.0 IU/L), and alpha-fetoprotein was not grossly elevated ( 10 μg/L), the fluid cytology was unremarkable. A provisional diagnosis of germinoma was made. Under local anaesthesia, a core needle biopsy via the percutaneous route through the foramen ovale guided by intraoperative CT-based neuronavigation with MRI fusion was executed (Fig. 2A and B). Briefly, the patient was placed in supine position, the ENT reference array (Kolibri™ ENT System, BrainLAB, Heimstetten, Germany) was secured to the patient’s forehead. A head CT scan was performed at 1.5-mm intervals, 120 kV, 120 mAs, with the Somatom Sensation Open sliding gantry CT
Discussion Biopsy of lesions in the parasellar region, provided it can be done with minimal morbidity, is preferred in certain instances over open surgery as it allows tissue-based pathological diagnosis, neoplastic or otherwise, in a step towards definitive therapy and prognostication, and it may avoid the risks of open surgery entirely. Biopsy of intracranial lesions is traditionally performed under stereotaxy via the transcranial route that is associated with a high diagnostic yield and a low morbidity. However, the accessibility of the parasellar region through the foramen ovale based on favourable preoperative simulation offers an alternative route for biopsy without the need of a burr hole and the added risks of brain transgression. The intraoperative registration technique
Correspondence: Jen-Tsung Yang, Department of Neurosurgery, Chung Gung Memorial Hospital, 6 Sec West, Chia Pu Rd, Pu Tz City, Chiayi, Taiwan. Tel: 886-5-3621000 extension 2864. Fax: 886-5-3623002. E-mail: [email protected] Received for publication 19 February 2014; accepted 7 June 2014
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Biopsy of parasellar lesion 797
Fig. 1. (A) and (B) Plain brain CT showing the cerebellopotine angle, suprasellar and pineal region tumours. (C) and (D). Contrast-enhanced MRI showing the same tumours.
using the ENT reference array provides a simple alternative to fiducial markers and neuronavigation-guided, percutaneous puncture also eliminates the bulk of the hardware in frame-based and frameless stereotactic systems. The technique of neuronavigation for the cannulation of foramen ovale has been demonstrated in several case series including our own for the treatment of trigeminal neuralgia.1 The necessity of neuronavigation for ablative procedures is debatable, but the superior visual-spatial information the system provides can be advantageous especially in those with a difficult-to-access foramen ovale. For ablative procedures, the target Gasserian ganglion occupies a relatively constant location to the foramen ovale, a greater emphasis is placed on the reproduction of pain in the affected trigeminal nerve distribution upon electrophysiologic stimulation, by contrast, in biopsy procedures, the location of the target lesion can be varied and more intimately associated with the critical neurovascular structures in the parasellar region, the biopsy needle may need to be advanced further beyond the opening of the foramen ovale, more towards the mid-line and supero-posterior structures, which may place the cavernous segment of the internal carotid artery and the
brainstem at risk, therefore, accurate trajectory planning, precise lesion targeting and visualization is essential. Messerer et al. presented the largest case series on the percutaneous biopsy of lesions in the cavernous sinus, their technique employed detailed pre-operative multi-modality image work-up and the aspiration of target lesion by the biopsy needle introduced coaxially under fluoroscopy, they reported a high diagnostic yield (sensitivity of 83% and specificity of 100%) and excellent concordance with the diagnosis made from open surgery (ĸ-coefficient of 0.81); however, the paucity of samples and the possibility of harvesting near the skull base and meninges might have accounted for the unproductive or discordant results.2 Sindou et al. also pointed out the approach-related difficulties in puncturing the foramen ovale under fluoroscopy, the potential for bleeding from a highly vascularized tumour, the inability to obtain samples from a firm or calcified tumour and contamination of the specimen.3 Furthermore, biopsy procedures performed under fluoroscopy is blind, indirect and relies on bony landmarks that can be inconspicuous and pre-operative simulations and trajectory planning may not always correspond to the
798
M. H.-C. Lin et al.
Fig. 2. (A) A 3D representation of the regional structures: foramen ovale (green), lateral pterygoid plate (yellow), brainstem (blue), carotid arteries (red) and tumour (purple), the trajectory is simulated (arrow). (B) Neuronavigation-guided puncture of the foramen ovale into the parasellar lesion. (C) Left, haematoxylin and eosin stain of the specimen revealed nests of abnormal large cells with scanty cytoplasm and vesicular nuclei. Right, positive reactivity for CD117 demonstrated via immunohistochemical staining. (D) Post-craniospinal irradiation after the first 11 fractions showing near complete regression of the tumours on contrast-enhanced T1-weighted MRI.
actual procedure done under fluoroscopy. The utilization of neuronavigation with the lesion highlighted on CT or MRI can potentially overcome many of the above mentioned limitations, even though it is not a strictly ‘real time’ image, the puncture of the foramen ovale can be executed swiftly, the exact location of the biopsy needle can be determined with greater certainty, the coaxial introducer needle can be inserted into the lesion to avoid contamination, serial CT may be performed to confirm needle placement if required, and multiple trajectories and needle passes can optimize the specimens obtained. The current literature lacks data on the accuracy of neuronavigation for the trans-foramen ovale biopsy of parasellar lesions, a cadaveric or phantom study of the system in the future would be of value in better defining the benefits of this approach.
Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper.
References 1. Lin MH, Lee MH, Wang TC, et al. Foramen ovale cannulation guided by intra-operative computed tomography with intergrated neuronavigation for the treatment of trigeminal neuralgia. Acta Neurochir (Wien) 2011;153:1593–9. 2. Messerer M, Dubourg J, Saint-Pierre G, Jouanneau E, Sindou M. Percutaneous biopsy of lesions in the cavernous sinus region through the foramen ovale: diagnostic accuracy and limits in 50 patients. J Neurosurg 2012;116:390–8. 3. Sindou M, Chavez JM, Saint Pierre G, Jouvet A . Percutaneous biopsy of cavernous sinus tumors through the foramen ovale. Neurosurgery 1997;40:106–10.
Copyright of British Journal of Neurosurgery is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
